Coats v. Commissioner of Social Security

Filing 22

OPINION AND ORDER: GRANTING 15 Social Security Opening Brief of Plaintiff. The decision of the ALJ is REMANDED for further proceedings consistent withthis opinion. Signed by Magistrate Judge Christopher A Nuechterlein on 5/19/2015. (lhc)

UNITED STATES DISTRICT COURT
NORTHERN DISTRICT OF INDIANA
SOUTH BEND DIVISION
JOHNNIE COATS,
Plaintiff,
v.
CAROLYN W. COLVIN,
Acting Commissioner of Social Security,
Defendant.

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CAUSE NO. 3:14-cv-813-CAN

ORDER
On April 9, 2014, Plaintiff Johnnie Coats (“Coats”) filed his complaint in this Court
seeking reversal of the Commissioner’s final decision denying his application Supplemental
Security Income (“SSI”) and Disability Insurance Benefits (“DIB”). On August 6, 2014, Coats
filed his Memorandum Of Law In Support Of A Social Security Appeal. [Doc. No. 15]. On
October 30, 2014, Defendant Commissioner of Social Security (“Commissioner”) filed a
response, asking the Court to affirm the Administrative Law Judge’s (“ALJ”) decision denying
Coats’s applications for SSI and DIB. Coats filed a reply on November 13, 2014. This Court may
enter a ruling in this matter based on the parties consent, 28 U.S.C. § 636(c), and 42 U.S.C. §
405(g).
I.

RELEVANT BACKGROUND
On July 12, 2011, Coats filed applications for DIB and SSI alleging an onset date of

January 15, 2011, due to a neck injury. After the SSA denied Coats’s applications initially and
upon reconsideration, an ALJ held a hearing regarding Coats’s applications on January 3, 2013.
Coats was born on January 12, 1961, making him 50 years old at the alleged onset date.
Coats completed the eleventh grade but did not obtain a GED. He lives with his girlfriend and

her son. Before the alleged onset date, Coats worked as a furnace operator, grinder, temporary
worker, and wire cutter. At his hearing before the ALJ, Coats testified that he broke his neck
while intoxicated and attempting to retrieve his spare key from a window ledge to unlock the
door to his house. Coats provided medical evidence, including records of doctor visits and
treatment for neck pain, from the date of the injury through the date of the hearing.
More specifically, Coats provided the ALJ with the medical opinions and treatment notes
from Dr. Roman Filipowicz, his treating neurosurgeon, and an RFC analysis by Dr. Ruiz, a State
agency reviewing physician. Dr. Filipowicz’s notes show that Coats was admitted to the hospital
after his fall for a fracture of the cervical spine. Coats underwent stabilization surgery on January
26, 2011, and was instructed to wear a neck brace until told otherwise. In July 2011, Dr.
Filipowicz referred Coats to the Center for Pain Control after Coats was kicked out of the
physical therapy program. On September 22, 2011, Dr. Ruiz performed a physical RFC
assessment as part of Coats’s disability application process. Dr. Ruiz’s RFC assessment
projected that by January 15, 2012, twelve months after the alleged onset date, Coats would be
able to perform light work. Treatment notes from the Center for Pain Control on January 13,
2012, reported findings consistent with a December 30, 2011, examination that showed guarded
walking and guarded performance of other activities. Later treatment notes in February 2012,
from the Center for Pain Control showed hypersensitivity and signs of nerve inflammation. In
August of 2012, Dr. Filipowicz wrote a letter opining that Coats was incapable of physical labor.
After the hearing, the ALJ issued a written decision reflecting the following findings
based on the five-step disability evaluation prescribed in the Social Security Administration’s
(“SSA’s”) regulations. At Step One, the ALJ found that Coats had not engaged in substantial
gainful activity since January 15, 2011, the alleged onset date. At Step Two, the ALJ found that

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the residual effects of a neck fracture were a severe impairment. At Step Three, the ALJ found
that Coats’s impairments did not meet or medically equal the severity of a listed impairment. The
ALJ also found that Coats had the residual functional capacity to perform light work with the
following limitations: lift and carry up to 20 pounds occasionally and 10 pounds frequently; not
limited in the amount of time that he is able to sit, stand, or walk throughout an eight hour
workday but required a cane while walking; could perform no more than occasional balancing,
stooping, kneeling, crouching, crawling, and climbing of ramps or stairs; could not climb
ladders, ropes, or scaffolds; limited in the ability to rotate, flex, or extended his neck; able to
perform bilateral overhead reaching occasionally; could not tolerate concentrated exposure to
extreme cold; could not drive, operate moving machinery, work at unprotected heights, around
exposed flames, or around large, unguarded bodies of water; or tolerate exposure to unguarded,
hazardous machinery. At Step Four, the ALJ found that Coats was unable to perform any past
relevant work. At Step Five, the ALJ considered Coats’s, education, work experience, and
residual functional capacity, from which he determined that jobs existed in the national economy
that Coats could perform, such as an encapsulator or school bus monitor.
Based on these findings, the ALJ determined that Coats had not been disabled from
January 15, 2011, which was reflected in his written decision issued on January 24, 2013. Coats
requested that the Appeals Council review the decision of the ALJ and on February 7, 2014, the
Appeals Council denied the request. Thus, the ALJ’s decision became the final decision of the
Commissioner for the purposes of judicial review.
II.

ANALYSIS
A.

Standard of Review

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The Social Security Act authorizes judicial review of the final decision of the agency and
indicates that the Commissioner’s factual findings must be accepted as conclusive if supported
by substantial evidence. 42 U.S.C. § 405(g). Thus, a court reviewing the findings of an ALJ will
reverse only if the findings are not supported by substantial evidence or if the ALJ has applied an
erroneous legal standard. See Briscoe v. Barnhart, 425 F.3d 345, 351 (7th Cir. 2005). Substantial
evidence is more than a mere scintilla but may be less than the weight of the evidence. Scheck v.
Barnhart, 357 F.3d 697, 699 (7th Cir. 2004) (citations omitted). Thus, substantial evidence is
simply the relevant evidence needed for a reasonable mind to accept as adequate support for a
conclusion. Kepple v. Massanari, 268 F.3d 513, 516 (7th Cir. 2001) (citations omitted).
A court reviews the entire administrative record but does not reconsider facts, re-weigh
the evidence, resolve conflicts in evidence, decide questions of credibility, or substitute its
judgment for that of the ALJ. See Boiles v. Barnhart, 395 F.3d 421, 425 (7th Cir. 2005). Thus,
the question upon judicial review of an ALJ’s finding that a claimant is not disabled within the
meaning of the Social Security Act is not whether the claimant is, in fact, disabled, but whether
the ALJ “uses the correct legal standards and the decision is supported by substantial evidence.”
Roddy v. Astrue, 705 F.3d 631, 636 (7th Cir. 2013) (citations omitted). “[I]f the Commissioner
commits an error of law,” the Court may reverse the decision “without regard to the volume of
evidence in support of the factual findings.” White v. Apfel, 167 F.3d 369, 373 (7th Cir. 1999)
(citation omitted).
At a minimum, an ALJ must articulate his analysis of the evidence in order to allow the
reviewing court to trace the path of his reasoning and to be assured that the ALJ considered the
important evidence. See Scott v. Barnhart, 297 F.3d 589, 595 (7th Cir. 2002). An ALJ must
“build an accurate and logical bridge from the evidence to [the] conclusion so that [the court]

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may assess the validity of the agency’s final decision and afford [a claimant] meaningful
review.” Giles v. Astrue, 483 F.3d 483, 487 (7th Cir. 2007) (quoting Scott, 297 F.3d at 595)
(internal quotation marks omitted). Although the ALJ is not required to specifically address
every piece of evidence in the record, there must be a “logical bridge” from the evidence to the
ALJ’s conclusions. O’Connor Spinner, 627 F.3d at 618. The ALJ must provide a glimpse into
the reasoning behind the ALJ’s analysis and decision to deny benefits. Zurawski v. Halter, 245
F.3d 881, 889 (7th Cir. 2001).
B.

Disability Standard

To be eligible for disability benefits, a claimant must establish that he suffers from a
“disability” as defined by the Social Security Act and regulations. The Act defines “disability” as
an inability to engage in any substantial gainful activity by reason of any medically determinable
physical or mental impairment that can be expected to result in death or that has lasted or can be
expected to last for a continuous period of not less than twelve months. 42 U.S.C.
§§ 423(d)(1)(A), 1382c(a)(3)(A). To be found disabled, the claimant’s impairment must not only
prevent him from doing his previous work, but considering his age, education, and work
experience, it must also prevent him from engaging in any other type of substantial gainful
activity that exists in significant numbers in the economy. 42 U.S.C. §§ 423(d)(2)(A),
1382c(a)(3)(B); 20 C .F.R. §§ 404.1520(e)-(f), 416.920(e)-(f).1
When a claimant alleges a disability, Social Security regulations provide a five-step
inquiry to evaluate whether the claimant is entitled to benefits. 20 C.F.R. §§ 404.1520(a)(4). The
steps are: (1) Is the claimant engaged in substantial gainful activity? If yes, the claimant is not
disabled, and the claim is denied; if no, the inquiry proceeds to step two; (2) Does the claimant

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Because both SSI and DIB regulations are identical, the Court will only refer to the DIB regulations found in 20
C.F.R. pt. 404 in this order.

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have an impairment or combination of impairments that are severe? If not, the claimant is not
disabled, and the claim is denied; if yes, the inquiry proceeds to step three; (3) Do(es) the
impairment(s) meet or equal a listed impairment in the appendix to the regulations? If yes, the
claimant is automatically considered disabled; if not, then the inquiry proceeds to step four; (4)
Can the claimant do the claimant’s past relevant work? If yes, the claimant is not disabled, and
the claim is denied; if no, then the inquiry proceeds to step five; (5) Can the claimant perform
other work given the claimant’s residual functional capacity (“RFC”), age, education, and
experience? If yes, then the claimant is not disabled, and the claim is denied; if no, the claimant
is disabled. 20 C.F.R. § 404.1520(a)(4)(i)-(v); see also Scheck, 357 F.3d at 699-700 (7th Cir.
2004).
At steps four and five, the ALJ must consider an assessment of the claimant’s RFC. The
RFC “is an administrative assessment of what work-related activities an individual can perform
despite [the individual’s] limitations.” Dixon v. Massanari, 270 F.3d 1171, 1178 (7th Cir. 2001).
The RFC should be based on evidence in the record. Craft v. Astrue, 539 F.3d 668, 676 (7th Cir.
2008) (citing 20 C.F.R. § 404.1545(a)(3)). The claimant bears the burden of proving steps one
through four, whereas the burden at step five is on the ALJ. Zurawski, 245 F.3d at 886; see also
Knight v. Chater, 55 F.3d 309, 313 (7th Cir. 1995).
C.

Issues Presented for Review

Coats seeks remand in this case and contends it is appropriate for three reasons. First,
Coats contends that the ALJ’s RFC finding was not supported by substantial evidence. Second,
Coats contends that the ALJ erred in making the credibility determination. Third, Coats contends
that the ALJ’s step 5 finding was not supported by substantial evidence. The Commissioner

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generally contends that the ALJ’s findings and decisions were supported by substantial evidence.
The Court addresses each contention in turn.
1. Coats’s RFC Argument
First, Coats contends that the ALJ’s RFC finding was not supported by substantial
evidence. More specifically, Coats argues that the ALJ erred in weighing and evaluating the
medical evidence and opinions in the record. Coats seems to be particularly concerned that the
ALJ over-valued Dr. Ruiz’s projected RFC, which Coats asserts is inconsistent with later
treatment notes from the Center for Pain Control, and under-valued Dr. Filipowicz’s opinions
about Coats’s limitations. The opinions of treating physicians are generally entitled to greater
weight than those of examining physicians, and opinions of examining physicians are entitled to
greater weight than those of non-examining physicians. 20 C.F.R. § 416.927(d)(1)-(2). As long
as a treating physician's opinion is “well-supported by medically acceptable clinical and
laboratory diagnostic techniques” and is “not inconsistent with other substantial evidence” in the
case record, the ALJ should give it controlling weight. Id. When well-supported contradicting
evidence is introduced, the treating physician’s evidence is no longer entitled to controlling
weight. 20 C.F.R. § 404.1527(d)(2). Medical evidence may be discounted if it is internally
inconsistent or inconsistent with other evidence. 20 C.F.R. § 404.1527(c).
The essence of Coats’s argument, as the Court interprets it, is that the ALJ should have
given greater weight to Dr. Filipowicz’s July 2011 opinion, included in his letter referring Coats
to the Center for Pain Control, that Coats was “not a candidate to return to work” and his August
2012 opinion that Coats was “rendered incapable of physical labor.” [Doc. No. 15 at 16; 11 at
24, 25, 505, 532]. The ALJ gave minimal weight to Dr. Filipowicz’s July 2011 referral letter
because it did not contain any specific functional limitations and was written before Coats began

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treatment at the Center for Pain Control. The ALJ also gave minimal weight to Dr. Filipowicz’s
August 2012 letter, which state Coats was incapable of performing physical labor due to arm
pain, because the record did not show any functional limitations with arms. The ALJ gave great
weight to Dr. Ruiz’s RFC assessment performed on September 22, 2011, which predicted that by
January 15, 2012, Coats would be able to perform light work, because it was consistent with the
evidence in record that showed a history of treatment for pain in his spine. Coats argues that the
ALJ’s rationale for distribution of weight is without basis and that the record needed to be further
developed. Coats contends that the ALJ should have re-contacted Dr. Filipowicz, the treating
neurosurgeon, or ordered an updated consultative examination to properly develop a full and fair
record. The Commissioner provides a general argument that the ALJ supported his decision with
substantial evidence. While the Commissioner provided accurate statements of Social Security
law and analysis for the facts in this case, it is difficult to discern how these statements affect the
separate and specific issues raised by Coats.
Coats’s first argument for why the RFC is not supported by substantial evidence is that
the ALJ overly relied on the projected RFC assessment by Dr. Ruiz. Coats contends this was
error because the projected RFC assessment is contradicted by the Center for Pain Control’s
treatment notes in January 13, 2012, two days from when Dr. Ruiz had projected that Coats
would be able to perform light work. Coats points to treatment notes in December 2011 and
January 2012, which note his guarded ambulation and guarded performance of other activities, to
show that Coats’s impairments had not improved to the level predicted by Dr. Ruiz. [Doc. No. 15
at 19-20].
An ALJ must create a logical bridge from the evidence to the decision so that a reviewing
court can trace the path of his reasoning and be assured that the ALJ considered the important

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evidence. See Scott, 297 F.3d at 595; Giles, 483 F.3d at 487. Here, the ALJ has not articulated
his reasoning in balancing the treatment notes and Dr. Ruiz’s projected RFC. [See Doc. No. 13 at
24]. The ALJ’s discussion of the treatment notes in exhibit 12F and 14F relates to the treatment
received by Coats, and the discussion of Dr. Ruiz’s RFC assessment does not mention the
evidence considered in support or opposition of Dr. Ruiz’s assessment. [Doc. No. 13 at 24].
Therefore, this Court is unable to determine whether substantial evidence supports the ALJ’s
decision to give great weight to Dr. Ruiz’s opinion and the resulting RFC determination and
remand is appropriate.
Coats’s second argument for remand was that the ALJ failed to ensure a full and fair
record on which to base the RFC determination. Although the ALJ has the duty to ensure a full
and fair record, a court will only determine that the ALJ inadequately performed this duty when
there are significant gaps in the claimant’s medical record. Nelms v. Astrue, 553 F.3d 1093, 1098
(7th Cir. 2009). See also 20 C.F.R. § 404.1519a(b) (“A consultative examination may be
purchased when the evidence as a whole, both medical and nonmedical, is not sufficient to
support a decision on [the] claim.”). An omission or gap is significant only when it is prejudicial.
Nelms, 553 F.3d at 1098. To prove prejudice, the claimant must set forth specific, relevant facts
that the ALJ did not consider. Id.
Here, Coats first argues that the ALJ did not ensure a full and fair record because the ALJ
neither re-contacted Dr. Filipowicz nor ordered an updated consultative examination to supply
the specific functional limitations that were not present in Dr. Filipowicz’s July 2012 letter
referring Coats to the Center for Pain Control. Coats contends that the “ALJ should have
recontacted Dr. Filipowicz for a function-by-function assessment . . . .” and that the ALJ “would
have made a more informed opinion with a functional assessment” from Coats’s treating

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neurosurgeon. [Doc. No 15 at 17-18]. However, a claimant’s mere speculation that more
information might have been obtained in the case does not warrant remand. Nelms, 553 F.3d at
1098. To succeed on this argument, Coats must provide specific evidence that the ALJ did not
consider, and show that the omitted evidence was relevant to the decision. Coats has failed to
meet this burden. Coats speculates that additional evidence may have been obtained from Dr.
Filipowicz had the ALJ re-contacted him. If Coats believed that he needed more evidence to
prove or show specific functional limitations, then he should have submitted the evidence at or
before the hearing. The ALJ was under no affirmative duty to pursue every piece of possible
evidence. See Nelms, 553 F.3d at 1098 (“there is no absolute requirement that an ALJ update the
medical records to the time of the hearing”) (citing Luna v. Shalala, 22 F.3d 687, 692-93).
Coats’s second argument for why the record was not complete is that the ALJ overly
relied on the projected RFC assessment by Dr. Ruiz. Coats contends this was error because the
projected RFC assessment is contradicted by the Center for Pain Control’s treatment notes in
January 13, 2012, two days from when Dr. Ruiz had projected that Coats would be able to
perform light work. Coats points to treatment notes in December 2011 and January 2012, which
note his guarded ambulation and guarded performance of other activities, to show that Coats’s
impairments had not improved to the level predicted by Dr. Ruiz. [Doc. No. 15 at 19-20].
This argument is similarly unpersuasive in proving a significant gap or omission in the
record because the evidence that Coats claims contradicts Dr. Ruiz’s projected assessment was
actually considered by the ALJ. The ALJ cited to exhibits 12F and 14F, which include the
relevant treatment notes, when discussing Coats’s medication regimen. [Doc. No. 13 at 24].

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Therefore, as discussed above, this Court is unable to determine whether substantial
evidence supports the ALJ’s decision to give great weight to Dr. Ruiz’s opinion and the resulting
RFC determination and remand is appropriate.
2. Coats’s Credibility Argument
Coats’s second main contention is that the ALJ’s credibility determination was not
supported by substantial evidence because the ALJ did not discuss or analyze his daily activities,
which Coats claims would have supported a higher credibility determination. The Commissioner
argues that the ALJ properly considered the medical and non-medical evidence in the record and
provided sufficient reasons for discounting Coats’s credibility. When making a credibility
determination, the ALJ must consider the record as a whole, including objective medical
evidence, the claimant’s statement about symptoms, any statements or other information
provided by treating or examining physicians and other persons about the conditions and how
they affect the claimant, and any other relevant evidence. See SSR 96-7p. The standard of review
for an ALJ’s credibility determination is very deferential. Prochaska v. Barnhart, 454 F.3d 731,
738 (7th Cir. 2006). Generally, the credibility determination is considered a factual matter where
the ALJ is in the best position to determine the truthfulness and forthrightness of a witness, and
therefore courts will only overturn an ALJ’s credibility determination if it is patently wrong. See
Shideler v. Astrue, 688 F.3d 306, 310-11 (7th Cir. 2012); Herron v. Shalala, 19 F.3d 329, 335
(7th Cir. 1995). An ALJ’s credibility determination is “patently wrong” only when the
determination lacks any explanation or support. See Elder v. Astrue, 529 F.3d 408, 413-14 (7th
Cir. 2008).
In determining Coats’s credibility, the ALJ noted that there were “a number of factors
that weigh against the credibility of [Coats’s] allegations that his impairments are so severe that

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they cause him to be unable to work.” [Doc. No. 11 at 25]. First, the ALJ noted that there were
no functional limitations in the record from any of Coat’s doctors that would suggest greater
limitations than provided for in the RFC. Second, the ALJ noted that Coats was discharged from
physical therapy for failing to attend 5 sessions in a three month span and refusing further
treatment. Further, ALJ noted that the evidence of record reflected that Coats’s treatments were
successful in minimizing his symptoms and that Coats testified that his “medications work well
when he takes them.” [Doc. No. 11 at 25 (internal quotation marks omitted)]. The ALJ noted that
these were inconsistent with Coats’s claims that he needs to rest for 15 minutes after walking for
a block and that he could not sit for more than 2 hours.
Coats contends that the ALJ erred by discussing Coats’s noncompliance with
recommended therapy, dismissal from physical therapy for missing too many sessions, and the
lack of any documented opinion containing specific functional limitations. Coats also contends
that the ALJ erred by interpreting Coats’s testimony that his medicine worked well when he took
them as inconsistent with his claimed physical limitations. Finally, Coats contends that the ALJ
failed to discuss Coats’s daily activities, which Coats claims would support finding him more
credible. However, the ALJ provided specific support and explanations of the evidence that
lessened Coats’s credibility and thus, this Court cannot say that the determination was patently
wrong.
3. Coats’s Step 5 Argument
Finally, Coats argues the ALJ’s Step 5 determination was err because it did not include
further limitations, which would have been required if the ALJ had given more weight to Dr.
Filipowicz’s opinion in making the RFC determination. Although, Coats does not provide any
specific limitations that should have been included, the Court need not reach a decision on these

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arguments because the case is being remanded and the hypotheticals posed may change based on
the analysis provided in determining the RFC.
III.

CONCLUSION
For the reasons set out above, the Court GRANTS Coats’s request for remand this case.

[Doc. No. 15]. The decision of the ALJ is REMANDED for further proceedings consistent with
this opinion.
SO ORDERED.
Dated this 19th day of May, 2015.
s/Christopher A. Nuechterlein
Christopher A. Nuechterlein
United States Magistrate Judge

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